Provider Demographics
NPI:1689457210
Name:GREEN, JENNA DANIELLE LEAVITT
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:DANIELLE LEAVITT
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 MADISON PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-2158
Mailing Address - Country:US
Mailing Address - Phone:617-513-1056
Mailing Address - Fax:
Practice Address - Street 1:1413 MADISON PL
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-2158
Practice Address - Country:US
Practice Address - Phone:617-513-1056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4638609103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool